Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dermott City Nursing Home during CMS and state inspections, most recent first.
A CNA transferred a resident without using the required mechanical stand-up lift or a second staff member, contrary to the care plan. After the resident fell and complained of pain, two CNAs moved the resident to a wheelchair before a nurse assessment. The resident, who had a history of falls and required two-person assist for transfers, sustained an acute femoral fracture requiring surgery. Staff interviews confirmed the care plan and post-fall protocols were not followed.
The facility did not have a Licensed Administrator overseeing daily operations for several months after the previous Administrator resigned. During this period, administrative duties were not properly fulfilled, with a Compliance Officer—who lacked the required Administrator's license—listed as interim Administrator on official reports, including those related to a resident injury. The facility had not interviewed any candidates for the position and was still seeking a replacement.
A resident with cognitive impairment and mobility deficits, care planned for two-person assistance with a mechanical stand-up lift for transfers, was transferred by a CNA without the required lift or second staff member. During the transfer, the resident fell and sustained a right femur fracture. Staff interviews confirmed the care plan was not followed, and the facility's policy requires adherence to care plan interventions.
The facility did not post required daily staffing information, including total hours worked by RNs, LPNs, CNAs, and resident census. Observations showed incomplete or missing logs, and interviews revealed a lack of training and clarity on responsibilities for posting this information.
The facility failed to serve meals according to the planned menu, affecting residents on mechanical soft diets. During lunch, a dietary staff member used an incorrect scoop size for pureed chicken and dumplings, and the kitchen ran out of cornbread, substituting regular bread. At supper, pureed baked beans were not served due to cross-contamination, and residents received alternative items instead.
The facility's dietary department failed to maintain proper food safety and hygiene practices. Staff did not wash hands or change gloves before handling food, and several food items were improperly stored or expired. Additionally, hot food items were served below the required temperature, violating the facility's policy on preventing foodborne illness.
A resident with memory problems and requiring total assistance for repositioning was observed multiple times without a pillow, leading to discomfort and improper neck alignment. Staff interviews confirmed the resident's dependency on staff for positioning and the absence of a pillow, despite another resident having two pillows. The facility's policy emphasized the importance of comfort and proper positioning.
A resident with multiple medical conditions, including hemiplegia and osteoporosis, was injured during a transfer when an RN attempted to move them alone, contrary to the care plan requiring two staff and a mechanical lift. The RN was not adequately trained on accessing the care plan, leading to the resident's fall and subsequent leg fracture.
The facility failed to operate under the direction of a licensed Administrator, affecting all 45 residents. The Acting Administrator, who was the Compliance Coordinator, confirmed that the previous Administrator had been absent since July and that she did not hold a nursing home administrator's license. Documentation assigning her as Acting Administrator was undated and unsigned. The facility's policy requires the Administrator to be licensed and responsible for the facility's day-to-day functioning and resident care policies.
Failure to Follow Transfer Protocols and Post-Fall Assessment Leads to Resident Injury
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to demonstrate competency in the care of a resident by not following the resident's care plan and by moving the resident prior to a nurse assessment following a fall. Specifically, one CNA attempted to transfer a resident from bed to wheelchair without using the required mechanical stand-up lift and without a second staff member to assist, as mandated by the resident's care plan. During this improper transfer, the resident's legs gave out, resulting in the resident falling to their knees on the floor. After the fall, the CNA requested assistance from another CNA, and together they moved the resident from the floor to a wheelchair before the resident was assessed by a nurse, despite the resident complaining of pain. Both CNAs admitted in interviews that moving the resident prior to a nurse's assessment was not appropriate. The resident was later found to have sustained an acute right femoral fracture, which required surgical intervention. The resident involved had a history of scoliosis, unsteadiness on feet, dementia, and was care planned for transfers with a mechanical stand-up lift and two-person assist due to dependency in activities of daily living and a recent history of falls and fractures. Staff interviews and record reviews confirmed that the care plan was not followed, and the required protocols for post-fall assessment were not adhered to, resulting in significant harm to the resident.
Removal Plan
- All licensed nursing staff and certified nursing assistants will be in-serviced by the Director of Nursing (DON)/designee on the proper steps taken after a resident has sustained a fall, to prevent serious harm, serious injury, serious impairment, or death.
- All Certified Nursing Assistants (CNAs) and licensed nurses will be educated and in-serviced by the DON/designee on proper resident transfers to prevent serious harm, serious injury, serious impairment or death.
- All CNAs and licensed nurses will be educated and in-serviced by the DON/designee on locating and reviewing the care plan prior to resident care and implementing the care plan during resident care to prevent serious harm, serious injury, serious impairment, or death.
- All licensed nurses and CNAs will be educated to check the Kardex /plan of care, located in the kiosk, on a resident and implement it, also the proper steps to take after a resident sustain a fall, and to be educated on the proper transfer technique to prevent serious harm, serious injury, or death.
- The DON/designee will visually monitor residents being transferred, visually monitor licensed nurses and certified nurse assistants on locating, reviewing the plan of care, and implementing the plan of care, also proper steps taken when a resident sustains a fall, by CNA, and licensed staff, to prevent serious harm, serious injury, or death 5 times a week for 8 weeks or until compliance is verified by Office of Long-Term Care.
- The DON/designee will present all findings to the monthly QAPI (Quality Assurance & Performance Improvement) committee for further review and recommendations.
Failure to Employ Licensed Administrator for Facility Oversight
Penalty
Summary
The facility failed to ensure that a Licensed Administrator was hired to oversee the day-to-day operations in accordance with federal, state, and local regulations. Review of the Administrator job description and facility policy confirmed that the position requires a current, unencumbered Administrator's license and that the governing body is responsible for ensuring proper management and oversight. However, interviews and documentation revealed that the facility had been without a licensed Administrator since the previous Administrator resigned in July 2025. The Compliance Officer, who was listed as the interim Administrator on official reports, confirmed she did not hold an Administrator's license and was not acting in that capacity. Further review of incident reports indicated that administrative duties were not being properly fulfilled, as evidenced by the Compliance Officer's name being listed in the Administrator's section of an incident report involving a resident injury. Interviews with the Director of Nursing and Human Resources confirmed that no one had been filling the Administrator role and that no candidates had been interviewed for the position since the resignation. The facility was actively advertising for the position but had not yet hired a replacement.
Failure to Implement Care Plan for Safe Resident Transfer
Penalty
Summary
The facility failed to consistently implement a comprehensive care plan for a resident with multiple diagnoses, including scoliosis, unsteadiness on feet, dementia, and a history of fractures and falls. The resident was assessed as having moderate cognitive impairment and required staff assistance for activities of daily living, including transfers, for which the care plan specified the use of a mechanical stand-up lift with two staff members. Despite this, on the day of the incident, a CNA attempted to transfer the resident without the stand-up lift and without a second staff member, resulting in the resident falling to the floor. The incident occurred when the CNA, believing the resident could bear weight and pivot, assisted the resident from bed to wheelchair without following the care plan's specified interventions. During the transfer, the resident's shoe slipped, causing the resident's legs to give out and leading to a fall. The CNA admitted to not using the stand-up lift and was uncertain if she had reviewed the care plan prior to providing care that day. Other staff, including another CNA and an LPN, confirmed that the resident was care planned for two-person assistance with a stand-up lift and that this protocol was not followed during the incident. As a result of the improper transfer, the resident sustained an acute fracture of the right femur, confirmed by radiology and requiring orthopedic consultation. Interviews with facility staff, including the DON and compliance officer, revealed that staff are expected to review and follow care plans for all residents, particularly regarding transfer methods. The facility's policy requires that care plan interventions be implemented as written, but in this case, the specified transfer protocol was not followed, directly leading to the resident's injury.
Failure to Post Required Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the required staffing data was posted daily, as evidenced by the absence of total number and actual worked hours for RNs, LPNs, CNAs, and the resident census on the daily staffing logs. Observations on multiple days revealed that the staffing logs did not display the necessary information, such as the total hours worked by staff and the resident census. The logs were either incomplete or missing for certain shifts and days, and the information was not visible to the public as required. Interviews with the DON, LPN, BOM, and HR revealed a lack of clarity and training regarding the responsibilities for filling out and posting the staffing logs. The DON indicated that the night shift nurse was responsible for placing the sheets out, but there was no confirmation that the nurse was trained on what information needed to be included. The LPN and HR staff also confirmed that they had not been instructed to include the total hours worked or the census on the logs. The BOM and HR used the census sheet for internal purposes but did not ensure it was publicly posted as required.
Failure to Adhere to Planned Menu and Serve Nutritional Meals
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu, impacting the nutritional needs of residents on mechanical soft diets. During lunch, a dietary staff member used a #8 scoop instead of the required #6 scoop to serve pureed chicken and dumplings, resulting in smaller portions than specified. The staff member admitted to not consulting the menu before serving. Additionally, the kitchen ran out of cornbread and substituted regular bread for seven residents because the dietary staff prioritized feeding employees first. During supper, residents on pureed diets did not receive pureed baked beans as planned. The dietary manager explained that the beans were discarded due to cross-contamination when a scoop fell into the prepared beans after being handled with a contaminated glove. Instead, residents were served mashed potatoes, pureed corn dogs, and tomato juice. These actions and inactions demonstrate a failure to adhere to the planned menu and ensure the nutritional needs of residents were met.
Food Safety and Hygiene Deficiencies in Dietary Department
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene practices, as observed during a survey. Dietary staff did not wash their hands or change gloves before handling food items, leading to potential contamination. For instance, a dietary staff member touched a box of plastic sheets and then handled glasses by their rims without washing hands. Another staff member handled various food items and equipment without changing gloves after touching potentially contaminated surfaces. Food storage practices were also found to be inadequate. Several opened boxes of food items in the walk-in refrigerator and freezer were not covered or sealed, including bacon, catfish patties, hamburger patties, and more. Additionally, expired food items, such as a container of cottage cheese, were not promptly removed from stock. An ice scoop holder was found with a black and beige residue, indicating a lack of cleanliness in the kitchen area. Furthermore, the facility did not maintain hot food items at the required temperature of 135 degrees Fahrenheit or above. Pureed chicken and dumplings, green beans, and bread with warm milk were served at temperatures below the standard. Similarly, chicken and dumplings and ground corn dogs were served at inadequate temperatures later in the day. These deficiencies highlight a failure to follow the facility's policy on preventing foodborne illness through proper employee hygiene and sanitary practices.
Failure to Provide Appropriate Bedding for Resident
Penalty
Summary
The facility failed to provide appropriate bedding for a resident who was observed multiple times without a pillow. The resident, who had short-term and long-term memory problems, required total assistance to turn and reposition in bed and was unable to voice discomfort or desired positioning. Observations by the surveyor on different occasions revealed the resident lying in bed without a pillow, using their hand or the mattress to support their head, which was noted to cause a bend in the neck. Interviews with facility staff, including a CNA and an LPN, confirmed that the resident was not capable of positioning themselves and was dependent on staff for assistance. The LPN acknowledged the absence of a pillow and noted that another resident in the room had two pillows. Both the Administrator and the Director of Nursing confirmed that the resident was unable to position themselves and that the lack of a pillow could affect the resident's neck posture. The facility's policy on repositioning emphasized the importance of promoting comfort and preventing skin breakdown, circulation issues, and pressure relief for residents.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to safely transfer a resident in accordance with their care plan, resulting in a major injury. The resident, who had diagnoses including renal osteodystrophy, cerebral infarction, hemiplegia, and osteoporosis, was dependent on two staff members for transfers and required a mechanical lift. However, a Registered Nurse (RN) attempted to transfer the resident alone, without using the required lift, leading to the resident missing the wheelchair and being lowered to the floor. This incident resulted in a non-displaced fracture to the resident's right proximal tibia and fibula. The RN involved in the incident was not adequately trained on accessing the resident's care plan and Kardex, which would have informed her of the necessary interventions for safe transfers. Despite being in-serviced on using the kiosk, the RN admitted to not knowing how to use it and relied on instincts during the transfer. The Director of Nursing stated that all staff are trained during orientation and receive annual in-services, but the RN's lack of knowledge indicates a gap in training effectiveness. The facility's policy on fall prevention was not adhered to, as the resident was not evaluated for risk of falls, and successful interventions were not continued to prevent the incident.
Facility Lacks Licensed Administrator
Penalty
Summary
The facility failed to operate under the direction of a licensed Administrator, which had the potential to affect all 45 residents residing in the facility. On October 21, 2024, a surveyor was informed by the Director of Nursing (DON) and the Acting Administrator, who was the Compliance Coordinator, that no licensed Administrator was currently employed at the facility. The Acting Administrator confirmed that the previous Administrator had been absent since July 15, 2024, and the position had been posted on employment websites. However, the Acting Administrator did not hold a nursing home administrator's license. Furthermore, when asked for documentation assigning her as Acting Administrator, she provided an undated typed document without a name or signature of the person who assigned her the position. A review of the facility's policy titled 'Administrator' revealed that the Administrator is responsible for the day-to-day functioning of the facility, implementing established resident care policies, ensuring residents' rights, ensuring adequate staffing to meet residents' needs, and ensuring that only residents who can be adequately cared for by staff are admitted. The policy also stated that the Administrator must be duly licensed in accordance with federal, state, and local laws.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dermott
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Village Rehabilitation And Care Center | 16.7 mi | ★★★★★ | 6 | 0 |
| The Woods, A Nightingale Community | 21.4 mi | ★★★★★ | 0 | 0 |
| Belle View Estates Rehabilitation And Care Center | 22.1 mi | ★★★★★ | 0 | 0 |
| Legacy Manor Nursing And Rehabilitation Center | 23.9 mi | ★★★★★ | 2 | 0 |
| River Heights Healthcare Center | 24.3 mi | ★★★★★ | 9 | 0 |
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